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Swaminathan A, Sparrow MP. Perianal Crohn’s disease: Still more questions than answers. World J Gastroenterol 2024; 30:4260-4266. [DOI: 10.3748/wjg.v30.i39.4260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/17/2024] [Accepted: 09/23/2024] [Indexed: 10/12/2024] Open
Abstract
In this editorial we comment on the article by Pacheco et al published in a recent issue of the World Journal of Gastroenterology. We focus specifically on the burden of illness associated with perianal fistulizing Crohn’s disease (PFCD) and the diagnostic and therapeutic challenges in the management of this condition. Evolving evidence has shifted the diagnostic framework for PFCD from anatomical classification systems, to one that is more nuanced and patient-focused to drive ongoing decision making. This editorial aims to reflect on these aspects to help clinicians face the challenge of PFCD in day-to-day clinical practice.
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Affiliation(s)
- Akhilesh Swaminathan
- Department of Medicine, University of Otago, Christchurch 8011, Canterbury, New Zealand
- Department of Gastroenterology, Alfred Health, Melbourne 3004, Victoria, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, The Alfred Hospital, Melbourne 3004, Victoria, Australia
- Department of Gastroenterology, Alfred Health and School of Translational Medicine, Monash University, Melbourne 3004, Victoria, Australia
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Hanna LN, Anandabaskaran S, Iqbal N, Geldof J, LeBlanc JF, Dige A, Lundby L, Vermeire S, D'Hoore A, Verstockt B, Bislenghi G, De Looze D, Lobaton T, Van de Putte D, Spinelli A, Carvello M, Danese S, Buskens CJ, Gecse K, Hompes R, Becker M, van der Bilt J, Bemelman W, Sebastian S, Moran G, Lightner AL, Wong SY, Colombel JF, Cohen BL, Holubar S, Ding NS, Behrenbruch C, Sahnan K, Misra R, Lung P, Hart A, Tozer P. Perianal Fistulizing Crohn's Disease: Utilizing the TOpClass Classification in Clinical Practice to Provide Targeted Individualized Care. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00692-X. [PMID: 39134293 DOI: 10.1016/j.cgh.2024.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/26/2024] [Accepted: 06/11/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND & AIMS Perianal fistulation is a challenging phenotype of Crohn's disease, with significant impact on quality of life. Historically, fistulae have been classified anatomically in relation to the sphincter complex, and management guidelines have been generalized, with lack of attention to the clinical heterogenicity seen. The recent 'TOpClass classification system' for perianal fistulizing Crohn's disease (PFCD) addresses this issue, and classifies patients into defined groups, which provide a focus for fistula management that aligns with disease characteristics and patient goals. In this article, we discuss the clinical applicability of the TOpClass model and provide direction on its use in clinical practice. METHODS An international group of perianal clinicians participated in an expert consensus to define how the TOpClass system can be incorporated into real-life practice. This included gastroenterologists, inflammatory bowel disease surgeons, and radiologists specialized in PFCD. The process was informed by the multi-disciplinary team management of 8 high-volume fistula centres in North America, Europe, and Australia. RESULTS The process produced position statements to accompany the classification system and guide PFCD management. The statements range from the management of patients with quiescent perianal disease to those with severe PFCD requiring diverting-ostomy and/or proctectomy. The optimization of medical therapies, as well as the use of surgery, in fistula closure and symptom management is explored across each classification group. CONCLUSION This article provides an overview of the system's use in clinical practice. It aims to enable clinicians to have a pragmatic and patient goal-centered approach to medical and surgical management options for individual patients with PFCD.
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Affiliation(s)
- Luke N Hanna
- Department of Gastroenterology, St Mark's Hospital, London, United Kingdom.
| | - Sulak Anandabaskaran
- Department of Gastroenterology, School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, Australia
| | - Nusrat Iqbal
- Department of Colorectal Surgery, St Mark's Hospital, London, United Kingdom
| | - Jeroen Geldof
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Jean-Frédéric LeBlanc
- Department of Gastroenterology, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Anders Dige
- Department of Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Lilli Lundby
- Department of Colorectal Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospitals of Leuven, Leuven, Belgium
| | - André D'Hoore
- Department of Colorectal Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Bram Verstockt
- Department of Gastroenterology, University Hospitals of Leuven, Leuven, Belgium
| | - Gabriele Bislenghi
- Department of Colorectal Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Danny De Looze
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Triana Lobaton
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Dirk Van de Putte
- Department of Colorectal Surgery, University Hospital Ghent, Ghent, Belgium
| | - Antonino Spinelli
- Department of Colorectal Surgery, Humanitas Research Hospital, Milan, Italy
| | - Michele Carvello
- Department of Colorectal Surgery, Humanitas Research Hospital, Milan, Italy
| | - Silvio Danese
- IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | | | - Krisztina Gecse
- Department of Gastroenterology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Colorectal Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marte Becker
- Department of Gastroenterology, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Wilhelmus Bemelman
- Department of Colorectal Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Gordan Moran
- Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Amy L Lightner
- Department of Colorectal Surgery, Scripps Clinic, San Diego, California
| | - Serre-Yu Wong
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean-Frédéric Colombel
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Benjamin L Cohen
- Department of Gastroenterology, Cleveland Clinic, Cleveland, Ohio
| | - Stefan Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nik S Ding
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia
| | - Cori Behrenbruch
- Department of Colorectal Surgery, St Vincent's Hospital, Melbourne, Australia
| | - Kapil Sahnan
- Department of Colorectal Surgery, St Mark's Hospital, London, United Kingdom
| | - Ravi Misra
- Department of Gastroenterology, St Mark's Hospital, London, United Kingdom
| | - Phillip Lung
- Department of Radiology, St Mark's Hospital, London, United Kingdom
| | - Ailsa Hart
- Department of Gastroenterology, St Mark's Hospital, London, United Kingdom
| | - Phil Tozer
- Department of Colorectal Surgery, St Mark's Hospital, London, United Kingdom
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Alsoud D, Moes DJAR, Wang Z, Soenen R, Layegh Z, Barclay M, Mizuno T, Minichmayr IK, Keizer RJ, Wicha SG, Wolbink G, Lambert J, Vermeire S, de Vries A, Papamichael K, Padullés-Zamora N, Dreesen E. Best Practice for Therapeutic Drug Monitoring of Infliximab: Position Statement from the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2024; 46:291-308. [PMID: 38648666 DOI: 10.1097/ftd.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/21/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Infliximab, an anti-tumor necrosis factor monoclonal antibody, has revolutionized the pharmacological management of immune-mediated inflammatory diseases (IMIDs). This position statement critically reviews and examines existing data on therapeutic drug monitoring (TDM) of infliximab in patients with IMIDs. It provides a practical guide on implementing TDM in current clinical practices and outlines priority areas for future research. METHODS The endorsing TDM of Biologics and Pharmacometrics Committees of the International Association of TDM and Clinical Toxicology collaborated to create this position statement. RESULTS Accumulating data support the evidence for TDM of infliximab in the treatment of inflammatory bowel diseases, with limited investigation in other IMIDs. A universal approach to TDM may not fully realize the benefits of improving therapeutic outcomes. Patients at risk for increased infliximab clearance, particularly with a proactive strategy, stand to gain the most from TDM. Personalized exposure targets based on therapeutic goals, patient phenotype, and infliximab administration route are recommended. Rapid assays and home sampling strategies offer flexibility for point-of-care TDM. Ongoing studies on model-informed precision dosing in inflammatory bowel disease will help assess the additional value of precision dosing software tools. Patient education and empowerment, and electronic health record-integrated TDM solutions will facilitate routine TDM implementation. Although optimization of therapeutic effectiveness is a primary focus, the cost-reducing potential of TDM also merits consideration. CONCLUSIONS Successful implementation of TDM for infliximab necessitates interdisciplinary collaboration among clinicians, hospital pharmacists, and (quantitative) clinical pharmacologists to ensure an efficient research trajectory.
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Affiliation(s)
- Dahham Alsoud
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Zhigang Wang
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Rani Soenen
- Dermatology Research Unit, Ghent University, Ghent, Belgium
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Zohra Layegh
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Murray Barclay
- Departments of Gastroenterology and Clinical Pharmacology, Christchurch Hospital, Te Whatu Ora Waitaha and University of Otago, Christchurch, New Zealand
| | - Tomoyuki Mizuno
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Iris K Minichmayr
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | | | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Gertjan Wolbink
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center Location Reade, Amsterdam, Netherlands
- Sanquin Research and Landsteiner Laboratory, Department of Immunopathology, Amsterdam UMC, Amsterdam, Netherlands
| | - Jo Lambert
- Dermatology Research Unit, Ghent University, Ghent, Belgium
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Séverine Vermeire
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Annick de Vries
- Sanquin Diagnostic Services, Pharma & Biotech Services, Amsterdam, the Netherlands
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Núria Padullés-Zamora
- Department of Pharmacy, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain; and
- School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Chanchlani N, Lin S, Bewshea C, Hamilton B, Thomas A, Smith R, Roberts C, Bishara M, Nice R, Lees CW, Sebastian S, Irving PM, Russell RK, McDonald TJ, Goodhand JR, Ahmad T, Kennedy NA. Mechanisms and management of loss of response to anti-TNF therapy for patients with Crohn's disease: 3-year data from the prospective, multicentre PANTS cohort study. Lancet Gastroenterol Hepatol 2024; 9:521-538. [PMID: 38640937 DOI: 10.1016/s2468-1253(24)00044-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/31/2024] [Accepted: 02/09/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND We sought to report the effectiveness of infliximab and adalimumab over the first 3 years of treatment and to define the factors that predict anti-TNF treatment failure and the strategies that prevent or mitigate loss of response. METHODS Personalised Anti-TNF therapy in Crohn's disease (PANTS) is a UK-wide, multicentre, prospective observational cohort study reporting the rates of effectiveness of infliximab and adalimumab in anti-TNF-naive patients with active luminal Crohn's disease aged 6 years and older. At the end of the first year, sites were invited to enrol participants still receiving study drug into the 2-year PANTS-extension study. We estimated rates of remission across the whole cohort at the end of years 1, 2, and 3 of the study using a modified survival technique with permutation testing. Multivariable regression and survival analyses were used to identify factors associated with loss of response in patients who had initially responded to anti-TNF therapy and with immunogenicity. Loss of response was defined in patients who initially responded to anti-TNF therapy at the end of induction and who subsequently developed symptomatic activity that warranted an escalation of steroid, immunomodulatory, or anti-TNF therapy, resectional surgery, or exit from study due to treatment failure. This study was registered with ClinicalTrials.gov, NCT03088449, and is now complete. FINDINGS Between March 19, 2014, and Sept 21, 2017, 389 (41%) of 955 patients treated with infliximab and 209 (32%) of 655 treated with adalimumab in the PANTS study entered the PANTS-extension study (median age 32·5 years [IQR 22·1-46·8], 307 [51%] of 598 were female, and 291 [49%] were male). The estimated proportion of patients in remission at the end of years 1, 2, and 3 were, for infliximab 40·2% (95% CI 36·7-43·7), 34·4% (29·9-39·0), and 34·7% (29·8-39·5), and for adalimumab 35·9% (95% CI 31·2-40·5), 32·9% (26·8-39·2), and 28·9% (21·9-36·3), respectively. Optimal drug concentrations at week 14 to predict remission at any later timepoints were 6·1-10·0 mg/L for infliximab and 10·1-12·0 mg/L for adalimumab. After excluding patients who had primary non-response, the estimated proportions of patients who had loss of response by years 1, 2, and 3 were, for infliximab 34·4% (95% CI 30·4-38·2), 54·5% (49·4-59·0), and 60·0% (54·1-65·2), and for adalimumab 32·1% (26·7-37·1), 47·2% (40·2-53·4), and 68·4% (50·9-79·7), respectively. In multivariable analysis, loss of response at year 2 and 3 for patients treated with infliximab and adalimumab was predicted by low anti-TNF drug concentrations at week 14 (infliximab: hazard ratio [HR] for each ten-fold increase in drug concentration 0·45 [95% CI 0·30-0·67], adalimumab: 0·39 [0·22-0·70]). For patients treated with infliximab, loss of response was also associated with female sex (vs male sex; HR 1·47 [95% CI 1·11-1·95]), obesity (vs not obese 1·62 [1·08-2·42]), baseline white cell count (1·06 [1·02-1·11) per 1 × 109 increase in cells per L), and thiopurine dose quartile. Among patients treated with adalimumab, carriage of the HLA-DQA1*05 risk variant was associated with loss of response (HR 1·95 [95% CI 1·17-3·25]). By the end of year 3, the estimated proportion of patients who developed anti-drug antibodies associated with undetectable drug concentrations was 44·0% (95% CI 38·1-49·4) among patients treated with infliximab and 20·3% (13·8-26·2) among those treated with adalimumab. The development of anti-drug antibodies associated with undetectable drug concentrations was significantly associated with treatment without concomitant immunomodulator use for both groups (HR for immunomodulator use: infliximab 0·40 [95% CI 0·31-0·52], adalimumab 0·42 [95% CI 0·24-0·75]), and with carriage of HLA-DQA1*05 risk variant for infliximab (HR for carriage of risk variant: infliximab 1·46 [1·13-1·88]) but not for adalimumab (HR 1·60 [0·92-2·77]). Concomitant use of an immunomodulator before or on the day of starting infliximab was associated with increased time without the development of anti-drug antibodies associated with undetectable drug concentrations compared with use of infliximab alone (HR 2·87 [95% CI 2·20-3·74]) or introduction of an immunomodulator after anti-TNF initiation (1·70 [1·11-2·59]). In years 2 and 3, 16 (4%) of 389 patients treated with infliximab and 11 (5%) of 209 treated with adalimumab had adverse events leading to treatment withdrawal. Nine (2%) patients treated with infliximab and two (1%) of those treated with adalimumab had serious infections in years 2 and 3. INTERPRETATION Only around a third of patients with active luminal Crohn's disease treated with an anti-TNF drug were in remission at the end of 3 years of treatment. Low drug concentrations at the end of the induction period predict loss of response by year 3 of treatment, suggesting higher drug concentrations during the first year of treatment, particularly during induction, might lead to better long-term outcomes. Anti-drug antibodies associated with undetectable drug concentrations of infliximab, but not adalimumab, can be predicted by carriage of HLA-DQA1*05 and mitigated by concomitant immunomodulator use for both drugs. FUNDING Guts UK, Crohn's and Colitis UK, Cure Crohn's Colitis, AbbVie, Merck Sharp and Dohme, Napp Pharmaceuticals, Pfizer, and Celltrion Healthcare.
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Affiliation(s)
- Neil Chanchlani
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Simeng Lin
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Claire Bewshea
- Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Benjamin Hamilton
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Amanda Thomas
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rebecca Smith
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Christopher Roberts
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Maria Bishara
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rachel Nice
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Charlie W Lees
- Department of Gastroenterology, Edinburgh IBD Unit, Western General Hospital, NHS Lothian, Edinburgh, UK; Institute of Genetic and Cancer, University of Edinburgh, Edinburgh, UK
| | - Shaji Sebastian
- Gastroenterology and Hepatology, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK; Hull York Medical School, University of Hull, Hull, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children & Young People, Edinburgh, UK; Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young People, Edinburgh, UK
| | - Timothy J McDonald
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - James R Goodhand
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK.
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Truta B. Therapeutic drug monitoring in inflammatory bowel disease: At the right time in the right place. World J Gastroenterol 2022; 28:1380-1383. [PMID: 35645545 PMCID: PMC9099186 DOI: 10.3748/wjg.v28.i13.1380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/17/2022] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
Therapeutic drug monitoring (TDM) was one of most sought-after objective tools to determine therapeutic efficiency of different biologics and its role in the management of patients with inflammatory bowel disease (IBD) was regarded with great anticipation. But implementation of the TDM in clinical practice was challenged by several factors including uncertainty of the optimal cut-off values, assay variable sensitivity in detecting drug levels and antibodies and, most importantly, individual pharmacokinetics. While reactive TDM was embraced in clinical practice as a useful tool in assessing lack of response to therapy, the utility of proactive TDM in managing IBD therapy is still challenged by the lack of consistency between evidence. Described here, there are four groups of IBD patients for whom proactive TDM has the potential to greatly impact their therapeutic outcomes: Patients with perianal Crohn’s disease, patients with severe ulcerative colitis, pregnant women with IBD and children. As the future of IBD management moves towards personalizing treatment, TDM will be an important decision node in a machine learning based algorithm predicting the best strategy to maximize treatment results while minimizing the loss of response to therapy.
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Affiliation(s)
- Brindusa Truta
- Internal Medicine, Johns Hopkins University, Baltimore, MD 21210, United States
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Therapeutic Drug Monitoring in Perianal Fistulizing Crohn’s Disease. J Clin Med 2022; 11:jcm11071813. [PMID: 35407421 PMCID: PMC8999746 DOI: 10.3390/jcm11071813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 12/15/2022] Open
Abstract
Perianal fistulas are a common complication of Crohn’s disease (CD) that has, historically, been challenging to manage. Despite the strong available evidence that anti-tumor necrosis factor (anti-TNF) agents are useful in the treatment of perianal fistulizing Crohn’s disease (PFCD), a significant number of these patients do not respond to therapy. The use of therapeutic drug monitoring (TDM) in patients with CD receiving biologic agents has evolved and is currently positioned as an important tool to optimize and guide biologic treatment. Considering the treatment of PFCD can represent a challenge; identifying novel tools to improve the efficacy of current treatments is an important unmet need. Given its emerging role in other phenotypes of Crohn’s disease, the use of TDM could also offer an opportunity to enhance the effectiveness of available therapies and improve outcomes in the subset of patients with PFCD receiving biologics. Overall, there is mounting evidence that higher anti-TNF drug levels are associated with better rates of “fistula healing”. However, studies have been limited by their use of subjective outcomes and observational designs. Ultimately, further interventional, randomized controlled trials looking into the relationship between drug exposure and fistula outcomes are needed.
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Nones RB, Fleshner PR, Queiroz NSF, Cheifetz AS, Spinelli A, Danese S, Peyrin-Biroulet L, Papamichael K, Kotze PG. Therapeutic Drug Monitoring of Biologics in IBD: Essentials for the Surgical Patient. J Clin Med 2021; 10:jcm10235642. [PMID: 34884344 PMCID: PMC8658146 DOI: 10.3390/jcm10235642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/11/2022] Open
Abstract
Despite significant development in the pharmacological treatment of inflammatory bowel diseases (IBD) along with the evolution of therapeutic targets and treatment strategies, a significant subset of patients still requires surgery during the course of the disease. As IBD patients are frequently exposed to biologics at the time of abdominal and perianal surgery, it is crucial to identify any potential impact of biological agents in the perioperative period. Even though detectable serum concentrations of biologics do not seem to increase postoperative complications after abdominal procedures in IBD, there is increasing evidence on the role of therapeutic drug monitoring (TDM) in the perioperative setting. This review aims to provide a comprehensive summary of published studies reporting the association of drug concentrations and postoperative outcomes, postoperative recurrence (POR) after an ileocolonic resection for Crohn’s disease (CD), colectomy rates in ulcerative colitis (UC), and perianal fistulizing CD outcomes in patients treated with biologics. Current data suggest that serum concentrations of biologics are not associated with an increased risk in postoperative complications following abdominal procedures in IBD. Moreover, higher concentrations of anti-TNF agents are associated with a reduction in colectomy rates in UC. Finally, higher serum drug concentrations are associated with reduced rates of POR after ileocolonic resections and increased rates of perianal fistula healing in CD. TDM is being increasingly used to guide clinical decision making with favorable outcomes in many clinical scenarios. However, given the lack of high quality data deriving mostly from retrospective studies, the evidence supporting the systematic application of TDM in the perioperative setting is still inconclusive.
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Affiliation(s)
- Rodrigo Bremer Nones
- Health Sciences Postgraduate Program, School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba 80215-901, Brazil;
| | - Phillip R. Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| | | | - Adam S. Cheifetz
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (A.S.C.); (K.P.)
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy;
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy;
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy;
- IBD Centre, Humanitas Research Hospital, 20089 Milan, Italy
| | | | - Konstantinos Papamichael
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (A.S.C.); (K.P.)
| | - Paulo Gustavo Kotze
- Health Sciences Postgraduate Program, School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba 80215-901, Brazil;
- IBD Outpatient Clinics, Pontifical Catholic University of Paraná (PUCPR), Curitiba 80215-901, Brazil
- Correspondence:
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